Student overheard on interview tour: Boy, I really put one over on Perkins. I told him I wanted to be a Primary Care doctor…and he bought it. I’m sure to get in now.

What do we look for in medical students? No matter what, we want our physicians to be smart. The selection process is designed to weed out “not-smart” people. Unfortunately, we can only measure smart in a couple of different ways (grades and MCAT scores), ways that tend to benefit the wealthy (60% of medical students are from the upper quintile of income) and non-minority folks (14% of medical students are from underrepresented minorities compared to almost 25% of the population).

Is there another criteria we should use for selecting medical students? Altruism in medicine is best described in the words of this medical student:

So, for me, I see it as always putting yourself behind the person that you’re with. So the patient comes first, no matter what. If it means spending extra time past normal office hours to stay, if it means going out of your way for somebody, if it means sacrificing something for yourself, I think that’s what it is. First and foremost, you’re taking care of the patient.

Can we assess this in a medical school application? Unfortunately, not very well and not in a reproducible manner. We tend to put value on things we can quantify, so an MCAT equivalent of 37 (99th percentile) would attract the attention of the admissions committee much quicker than a prolonged experience at a soup kitchen. As one of my fellow admissions committee members said, “You can’t assay for the Give A Crap gene,” but you sure want your doctors to have it. The MCAT predicts how well the student will perform on tests but has no bearing on how good of a physician they will be. The soup kitchen experience may take away some grade and MCAT points, but give me that doctor-to-be every time.

Another marker is not the number of experiences but the intensity and commitment shown. The best people I have interviewed have been folks who have decided on medicine after several years of Teach For America or similar life experience. These folks tend to be better able to communicate with patients and, not coincidentally, tend to seek careers in primary care.

The best way to assess this, so they say, is through the interview process. As an interviewer, I will look at the student’s activities and query them regarding each of the things listed. Although not focused on primary care, I try to focus on whether or not the person has the GAC gene. To be honest, if in my opinion they don’t, I am not certain enough on my ability to assess to sabotage the application. If they do, I try to recruit them into our school. If not, I try to sell them on the other allopathic medical school in the state.

When I was a student at Tulane, there was a story (possibly apocryphal) that illustrates how medical education used to occur. The Endocrine Clinic (a training clinic for Internal Medicine residents) at Tulane used to take care of a lot of patients with overactive thyroids. They would place them on medication (Propylthiouracil, expensive, had to take three times a day) and monitor them roughly every 2 months from signs of worsening or problems with the medication. One Christmas break, the surgery residents broke into the clinic, pulled the charts of all of the patients on this medication, and called them to ask if they were interested in having an operation that would eliminate the need for this medication (but possibly lead to the need for thyroid replacement therapy). After the clinics reopened, many of these patients came back for their follow-up with a fresh scar from their thyroidectomy. The chairman of Medicine, a clinical giant named C. Thorpe Ray, went into the Dean’s office and proceeded to rant loudly about the surgeons. The chairman of Surgery, called in special for the occasion, let Dr. Ray rant. When asked for his response, he answered simply: “The boys need thyroids.”

This had been the training philosophy in medicine since the model for modern medical training was established following the Flexner Report. Learners were placed in large hospitals and practiced on folks who needed care. Folks in need went to the large hospitals to get care. Some folks might get care they didn’t need or want but… the boys needed thyroids.

Medical training, though, is changing.

A new report from the AAMC provides the results of a 2010 survey of member institutions to determine how attributes of the patient-centered medical home are being incorporated into the clinical education environment. While few studies have examined how medical homes have been integrated into teaching settings, “Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery,” offers examples of seven medical schools successfully delivering patient-centered care to their communities. The report also discusses the challenges and opportunities in the post-health care reform era for medical schools and teaching hospitals to develop new ways to train physicians and improve the health of the public.

And now Tulane offers community-based training at several Federally Qualified Community Health Centers across the city (from the AAMC report)

While training in an NCQA-recognized patient-centered medical home has profoundly affected the resident ambulatory experience, (there is currently a waiting list of residents who wish to train at Covenant House) their exposure to innovation extends outside the health center walls. The team has partnered with numerous local nonprofit civic and religious groups in efforts to “get our tentacles into the community,” and allow faculty, residents, and medical students to train community health workers through culturally sensitive care management programs. Faculty have noted the quick ability with which residents become “savvy” with the resources available to the community, and, as indicated by Dr. Price Haywood: “Residents play a key role in helping patients negotiate the community.”

There is a very good essay published in Family Medicine written by a physician who had a patient present to the Emergency Department essentially dead from Sudden Infant Death Syndrome. The essayist (who was on his way to teach a group of medical students) initially identifies his conflicting feelings of on the one hand knowing that he could not affect the outcome for his patient but on the other hand feeling like his presence might be of some use to the family. He is amazed at the magnitude of his contribution by the end of the essay.

It was humbling to reflect on how I had initially considered my responsibilities as a teacher more urgent than attending to the death of my patient. I felt ashamed when I remembered that I had thought because the baby was dead, there was nothing to do, no algorithm to follow, no intervention to aim toward an optimal target. Mandy’s and Joe’s loss left me deeply saddened and drained, yet in a strange way, a way that perhaps only other doctors would understand, the morning’s events also rejuvenated me.

He goes on to point out that as a faculty physician, he often preaches the evidence based approach and forgets the importance of ministering to the sick and the bereaved. This episode reminded him of the importance of relationships, a lesson which was lost in the day-to-day work of teaching medical students. He then went to class, apologized for missing the previous class and offered his students a lesson in professionalism and empathy based on his experience. I have observed that students do not understand the importance of these types of encounters. While nothing concrete happened, the essayist changed the outcome of the encounter just by being available. Patients want that level of commitment from their physician. There has always been a tension between the needs of the patient and the needs of the person wearing the mantle “Doctor.” In light of work hour concerns, declining patient satisfaction with the health care environment, and other problems, maybe we should place more emphasis on this aspect of medicine.

Can we teach people to “do the right thing?” Is it important that those of us who teach students understand these types of relationships? Isn’t connecting with people a skill that people ought to bring into medical school? Can it be taught?

If there is a problem, and many agree that there is, partly it may be the selection process. We tend to select wealthy students with exceptional grades who test well. These criteria may not select for empathetic future physicians.

A tendency towards “humanness” may be lost in the educational process. “Hardening of the hearts” of medical students has been described in the literature.

The results of this study suggest that student empathy is affected by medical education. Our study supports the findings of Coulehan and Williams, who described deleterious changes in various humanistic qualities as medical students became “immunized” against these values after their matriculation into medical school.

We may not put forth the best role models. Many academic physicians have a career trajectory that requires mobility. From medical school (4 years) to Residency (3-5 years) to Fellowship (an optional 1-3 years) to junior faculty (5 years) to mid-career leadership role (5 years) a medical school faculty member may have lived in 5 different cities in a span of 20 years. To a physician who has had such a career, relationships with patients likely will take a back seat to other aspects of technical practice such as technical skills. In medical schools such as ours, we combat this through the use of community preceptors for certain educational experiences (such as Family Medicine).

The good news is that it can be taught to physicians, even after graduation. From an article about malpractice prevention:

Practical means of sending a message of respect were identified in a study by Levinson.They include attention to body language (Do you look rushed?), efforts to solicit patients’ opinions (“Which option seems most workable for you?”), and encouraging patients to talk (“What can we talk about today?” followed by a mandatory pause). Such strategies take time. However, in the Levinson study, providers modeling respect-generating strategies averaged just over 3 minutes more per encounter than their colleagues who did not but who were subjects to suits

Can the medical profession do better? Admitting the correct folks into medical school and/or taking the time to assess and correct empathy deficits is important and will lead to physicians who are unable to generate an empathetic response seeking an alternative career path. Having role models among the full-time educators (with a clinical practice that includes continuity patients) such as the essayist may arrest the heart hardening effect of medical school. Identifying community champions of empathetic practice and placing students with these clinicians is important and will counteract the tendency of university physicians to minimize those relationships. Identifying those practicing physicians who slipped through the cracks and offering remediation will improve the situation as well.

As Family Physicians, strong supporters of structural change in healthcare, and the Family Medicine Department of the 8th most socially conscious medical school in the country we are not content to sit on the sidelines and wait to see “what form health care takes.” The Department has undertaken several initiatives that help us to demonstrate to students the full impact an engaged family medicine team can make in the health of a community. I sat down with each of the faculty over the past month and asked them to brief me on how these initiatives are progressing. Below I have chosen to highlight three of these initiatives:

First, at the entry level into medical school and throughout the preclinical year, it is important to identify those students interested in being a family physician. Dr Carol Motley is working with the 1st and 2nd year students (and lower) to develop an early interest in Family Medicine. I had the privilege of attending the organizational meeting for the Family Medicine Interest Group and was pleased to see the level of commitment and enthusiasm. The group will offer additional instruction for those interested in Family Medicine as well as an opportunity to interact with peers who share this interest. One of the things our specialty has done well is developed an infrastructure to assist departments such as ours in developing and maintaining interest. However, without dedicated students it doesn’t make much difference. I am excited to see committed, engaged students who want to be someone’s doctor.

Second, the medical students have a very intense clinical year where they learn the basics of clinical medicine and determine which type of doctor they want to be. Dr Ehab Molokhia has transformed our educational experience for our third year students. He has chosen to emphasize the Patient Centered Medical Home as his core curriculum. To that end, all of the educational activities that are not patient focussed targeted to teaching the students about what advantage a Patient Centered approach would bring to the patient in the exam room and collective ly to all te patients served by a Patient Centered practice. In addition, he is using actors to demonstrate effective care of the patient with chronic conditions to the learners. The evaluations are very good and the criticism that Family Physicians only take care of minor illnesses is being debunked.

Thirdly, it is important that we model care unique to the new model of Family Medicine. Dr Shyla Reddy, our resident geriatrician, is delivering care to elderly in a clinic without walls. She is partnering with the Mobile Housing Board to deliver care on site to elderly, home-bound residents in one of the need based elderly housing units. She will be using our electronic health record, practice resources, and resources from the community to allow seniors living in the complex to “age in place.” What she has found so far is that the residents of this complex (like elderly everywhere) are plagued by poorly coordinated care that often results in poorer health. She will make a real difference as will the rest of the team.

The faculty who work with me (I consider myself to be a member of their team, although I do get to set tone and direction) are dedicated to the delivery of high-end primary care. They are now finding ways to instruct students in these new methods of care delivery and model this care delivery to the populations who need it the most. This is happening in almost every College of Medicine with a Family Medicine department in the country. These are exciting times.

Bob Bowman has sent me the rest of his thoughts about my post regarding the Family Medicine’s role in the health care delivery system and I will share these with you (with a little commentary from me):

We started with “all he saw was a family practice doctor” – this was a comment that could have been made any time in the past 80 years. For the first twenty of those years medical educators such as Osler, Flexner, and various deans would defend the general practitioner as essential and of great value. The medical education leadership began with a perspective that was predominantly generalist and steadily transitioned to physicians more focused on subspecialty, hospital, and research areas.

One of the consequences of separations between types of physicians was the somewhat derogatory term LMD or Local MD. Town versus gown is another descriptive phrase for the competitive situation although in more recent decades, both town and gown physicians have been losing out. Control of accreditation, training, exclusive markets, health policy influences, associations, and journals has moved steadily toward physicians born, raised, educated, trained, and practicing in top concentrations. Over 70% of US physicians or more arise from about 25% of the population.

Josh Freeman has done a lot of work on this. He points out that not only are physicians-in-training overwhelmingly from caucasian families but also 15.7% of students had one or more parents who was a physician and 24.1% more had a non-physician professional parent. This is important because “…a student’s having a physician parent had a pervasive negative effect on graduates’ choice of any generalist-primary care specialty…” Bob goes on to point out:

An interesting month for healthcare in Alabama. First, Southeast Alabama Medical Center in Dothan announced a $40,000,000 investment in Osteopathic medical education. Scheduled to enroll 150 students in the fall of 2012, this school will “pay back” the investment through tuition. The stated purpose of this school is to develop physicians for the delivery of primary care in Alabama. According to the hospital CEO “The backdrop for all this is the scarcity of primary care physicians. The state’s medical schools, UAB and the University of South Alabama, produce specialists, cardiologist and surgeons, but there is a need for family-care physicians, especially in rural Alabama.”

The primary for Governor was Tuesday here in Alabama. On the Democratic side, the very bright and articulate Artur Davis lost to Ron Sparks, in part by alienating his base with a vote against healthcare reform. On the Republican side, Dr Robert Bentley came out of nowhere to (if the recount doesn’t change anything) challenge Bradley Byrne for the Republican nomination. Dr Bentley is one of the few candidates who responded to the Alabama Rural Health Association’s questions to the candidates. He too feels that the answer is more doctors. He told ARHA ” We want to establish the Alabama Health Service Corp which will set aside 25% of the seats in our medical schools for primary care this includes family medicine, internal medicine, pediatrics obgyn, and general surgery. These students will be given full scholarships and a place in medical school without lowering the quality of the emission standards. Upon completion of their residencies these physicians will give back to Alabama four years of full time service in an area of need. I was involved from the beginning in the Alabama Medical Education Consortium. This program deals with the education of Alabama students in osteopathic medical schools throughout the country. This summer we will have our first group of graduates that will enter practice most of these are primary care physicians. At present we have over 150 students in this program. We are working towards evolving the AMEC program in cooperation with certain hospitals in the wiregrass are to form an osteopathic medical school. This will give us a larger number of potential primary care physicians for the state of Alabama.”

It is a shame that the state of Alabama is providing tax-payer subsidized medical education to almost 300 students annually through its two existing medical schools, and yet we have such a need that we are going to have another medical school established just to put doctors in primary care in Alabama. This school will not be subsidized but instead will require the students to pay the entire cost of their education (about $50,000 annually vs about $17,000 for the state schools).

Until we change our delivery system, I suspect these students won’t go into primary care either. In Alabama we continue to have a delivery system that rewards episodic fee-for-service care over comprehensive patient centered primary care. We are not training medical students at USA and UAB to work with the medical team in a collaborative manner . I suspect that without delivery system reform, the increases in physicians promised by AMEC will likely not translate into increased numbers of primary care physicians in Alabama just as the formation of the University of South Alabama in the 1970s didn’t relieve the shortage. It will take the primary payors (Blue Cross/ Blue Shield of Alabama and Alabama Medicaid) making delivery system reform a priority, disregarding opposition from other interests, for the shortage to be resolved.

Now that I’m over 50, have enough grey hair, and have children in college, people occasionally ask me for career advice for their children. The question goes something like “My son/daughter thinks they might want to be a doctor. Would you be willing to talk to him/her about it?” I always am happy to have a conversation about medicine and have met some remarkable young men and women in the course of these conversations. Because it is again that time of the year, I thought I might post some of my thoughts. If you are already a doctor or have thoughts regarding the topic, feel free to add your two cents as well.

1) No matter what, we like our doctors smart. If you are even considering being a doctor you needed to start working on test skills in 8th grade because we pick our doctors based on test scores. This means that people who go to “good” school have an advantage as do people who come from wealthy families. If you struggle as a student we believe you will have trouble making it through the system. This is a real problem in rural America where the emphasis has not been on identifying smart students early and working to give them have more of an advantage. We are often not willing to take chances with marginal prospective doctors, no matter how well intentioned they are. We need more programs that help students from rural and underserved communities achieve because growing doctors from within is the best way to do it.

2) As a physician, you are guaranteed a very good living but not a great living. I realize that they tell people applying for medical school never to discuss money but I’m putting this out there. Me and my colleagues are paid at the top 5% of all earners in the richest country in the world. This allows you to live very comfortably but also puts you in an awkward position in that the majority of folks you care for will have a very different set of concerns and worries than you do. The other weird thing is that the way doctors are paid makes some doctors think they are rock stars when the money they make really reflects the weirdness of our payment system. This is problematic when the doctors feel like they are owed the money by society and the ground rules for paying change (which they do periodically). If you live up to every penny, it tends not to end well.

3) As a physician you will have to work hard, and not in the way you think. I compare myself to my chemical engineering friends. Both of us came out of school with a complex, technical knowledge base. The difference is that companies who hire engineers fully expect that after 10 years or less the knowledge will be outdated and the engineer will either move into management, attempt to stay current, or move into another field. As a physician you will need to keep up with medical literature at times when you are not seeing patients. This means a lot of after hours reading of medical journals when others are in bed, asleep. Although no one is making you, your patients and colleagues expect it.

4) You are always a doctor, even when you are off. Comes with the territory. Some of us like it, others don’t. This is more so in smaller towns where you will be recognized and asked to answer medical questions in the grocery but it happens to me in Mobile Alabama (often) and Marietta Georgia (rarely but there was one family get-together where my cousin cut a tendon with a knife…)

5) If you are nosey, it is a great job. When people are applying for medical school, I often hear “I like science” and “I want to help people” in various combinations. Liking science in the way it’s taught now isn’t a prerequisite to being a physician. Non-science majors often make the best physicians. The prospective physicians I know will do well are those who have been engaged in activities where they get to know the people that they help. Showing up on a Saturday with your fraternity to work on a Habitat project is not nearly as meaningful as volunteering for a hospice and getting to know the patient. Doctors are able to make people feel better just by being in the exam room. This can be a really cool thing. On the other hand, this is a job where people entrust you with their inner most secrets. If that doesn’t appeal to you, you’ll still get into medical school but it’ll be a long 40 years.

6) Just because you get into medical school, you can still blow it. If you are a jerk or greedy before you get in, turns out we can’t fix that in medical school. We put out some of the best doctors when all of the smart jerks were going into dot-com jobs and we didn’t have to interview them in the first place. If you have an entrepreneurial spirit, medicine may not be for you. You have the ability to harm patients if you can’t put their interest before your own self-interest.

The House of Representatives passed the Senate Health bill and then passed a packages of fixes to send back to the Senate. If the Senate does pass the package, the law will look like this. Below are highlights of the new law for Family Medicine:

Establish a national Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge. If the pilot program achieves stated goals of improving or not reducing quality and reducing spending, develop a plan for expanding the pilot program. (Establish pilot program by January 1, 2013; expand program, if appropriate, by January 1, 2016)

Create the Independence at Home demonstration program to provide high need Medicare beneficiaries with primary care services in their home and allow participating teams of health professionals
to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction. (Effective January 1, 2012)

Establish a grant program to support the delivery of evidence-based and community based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas. (Funds appropriated for five years beginning in FY 2010)

Provide states with new options for offering home and community-based services through a Medicaid state plan rather than through a waiver for individuals with incomes up to 300% of the maximum SSI payment and who have a higher level of need and permit states to extend full Medicaid benefits to individual receiving home and community-based services under a state plan. (Effective October 1, 2010

Provide a 10% bonus payment to primary care physicians and to general surgeons practicing in health professional shortage areas, from 2011 through 2015; Create new demonstration projects in Medicaid to pay bundled payments for episodes of care that include hospitalizations (effective January 1, 2012 through December 31, 2016); to make global capitated payments to safety net hospital systems (effective fiscal years 2010 through 2012); to allow pediatric medical providers organized as accountable care organizations to share in cost-savings (effective January 1, 2012 through December 31, 2016);and to provide Medicaid payments to institutions of mental disease for adult enrollees who require stabilization of an emergency condition(effective October 1, 2011 through December 31,2015)

Establish the Community-based Collaborative Care Network Program to support consortiums of health care providers to coordinate and integrate health care services, for low-income uninsured and underinsured populations.(Funds appropriated for five years beginning in FY 2011)

Establish a grant program to support the delivery of evidence-based and community based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas. (Funds appropriated for five years beginning in FY 2010)

Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011

Increase flexibility in laws and regulations that govern GME funding to promote training in outpatient settings (effective July 1, 2010); and ensure the availability of residency programs in rural and underserved areas. Establish Teaching Health Centers, defined as community based, ambulatory patient care centers, including federally qualified health centers and other federally-funded health centers that are eligible for Medicare payments for the expenses associated with operating primary care residency programs. (Initial appropriation in fiscal year 2010)

Increase workforce supply and support training of health professionals through scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training

Support the development of training programs that focus on primary care models such as medical homes, team management of chronic disease, and those that integrate physical and mental health services. (Funds appropriated for five years beginning in fiscal year 2010)

Todays Press Register carried an excerpt of an article from Governing Magazine which contrasted the differences in attitude towards health care reform between Alabama and New Mexico. The article made some interesting points which require some context to fully appreciate.

New Mexico has about half as many people as Alabama (2 million to 4.6 million) and is twice as big (120,000 square miles to 54,000 square miles) so is much more rural. Rurality poses a problem for care delivery for both states but Alabama health care is dominated by several largish cities (Birmingham, Mobile, Montgomery, Huntsville, and Tuscaloosa) that each have a medical school or a medical branch campus. Albuquerque is the only city of significant size in New Mexico. The medical education enterprise in Alabama is dominated by the University of Alabama, Birmingham has as its stated mission “The School of Medicine is dedicated to the education of physicians and scientists in all of the disciplines of medicine and biomedical investigation for careers in practice, teaching, and research. Necessary to this educational mission are the provision of outstanding medical care and services and the enhancement of new knowledge through clinical and basic biomedical research.” The medical school in New Mexico ” Our goal is to provide top-notch clinical services to the residents of New Mexico while being recognized as a respected School of Medicine training doctors for New Mexico.”

Both states are in the bottom quartile of state rankings. The difference is in how the state health officers see the role of health insurance refom in their path to becoming a high performing state. In Alabama, Commissioner Stekel sees impending doom. Alabama chooses to insure almost all of its children (97%) but relies on the medical schools to care for the poor adults as a by-product of the education process. As a result there are 100,000 diabetics in Alabama who do not get needed preventive services and either die prematurely or suffer significant disability. 250,000 of its citizens use the emergency rooms as their usual source of care. Although most children have insurance under the current system, 150,000 do not have access to primary care because of a shortage of providers to deliver that care. Commissioner Steckel wishes “more modest approach of incentives for small businesses and pooling had been tried instead.”

The Medicaid commissioner of New Mexico sees opportunity. The per capita numbers may look the same (or even a little worse) but New Mexico Medicaid Director Ingram sees ” it as a tremendous boost to the state economy. Those providers, in turn, will have more money to spend in ways that benefit New Mexico’s economy. Ingram points to a study conducted by the advocacy group New Mexico Voices for Children that found that each dollar spent by New Mexico on Medicaid generated $2.90 in federal Medicaid funds, which in turn generated an additional $2 in extra economic activity as the spending rippled through the economy, ultimately creating a combined “multiplier” effect of $4.90.”

Part of why Commissioner Stekel see impending doom where Director Ingraham sees opportunity may be how Academic Medicine fits into the care delivery system. At the University of New Mexico College of Medicine, many programs exist to enhance care delivery and integrate the clinical offerings into the communities. I saw a very impressive presentation of some of their telehealth activities at the National Rural Health Association meeting in Miami. I hope that we in academic medicine in Alabama will be offered the opportunity to work with Commissioner Steckel to do the same.

I was at a meeting of Family Medicine Department Chairs in Tuscon Arizona this past week. This is an exceptional meeting for hearing what other departments are doing regarding educating medical students, developing research activities around primary care, and learning about topics of importance to primary care (the Patient Centered Medical Home was the featured topic of the meeting). The reason to go to these meetings is to 1) confirm that you are doing stuff that others are doing and doing it better than they 2) confirm that you were correct in not doing stuff that seemed important at the time but you were convinced it would lead to disaster or 3) figure out how to make up for lost time when starting a task that should have been initiated several years ago.

This particular meeting featured a panel of exceptional students from the University of Arizona College of Medicine in Tuscon talking about what we (as educators) can do to foster interest in primary care. They were all committed to primary care and it was refreshing to hear from these idealistic students. Many of them were from rural Arizona or had life experiences that led them to enter medicine to make a difference in their patient’s lives. They did confess to being an exception in their class, with the majority of their fellow students focusing on materials needed for the test (the here and now) as opposed to the big picture.

I confess to having a pang of regret. Our students did not to me seem so idealistic when our department faculty attempt to offer instruction in social issues as a part of the Fundamentals of Doctoring course here in Mobile. I wondered if perhaps our school is not as effective as other schools in fostering an attitude of social justice. I wondered if our students were too focused on the high stakes exam (NBME Step I) to get the big picture we were trying to draw for them. That was why I was pleased to receive a very nice e-mail today thanking my department for the perspective we bring to the 1st and 2nd year of medical school. It made me feel that maybe our efforts are worthwhile.

A long way of asking you to thank one of your teachers today…it’ll make them feel better.